论文部分内容阅读
病历摘要患者(住院号15960)男,37岁,1976年元月中旬,出差途中发生持续性上腹隐痛,伴恶心、纳差、乏力,未觉发热。服“胃舒平”不缓解,病后5天,解黑色稀便,每日1—2次。入院前3天凌晨,突然恶心、呕吐暗红色血性胃内容物约300毫升,1976年2月4日转我院。既往有“胃病”史。近5年有疫水接触史,否认有血吸虫病,亦无黄疸或肝炎史。无烟酒嗜好。家族史无特殊。入院体检,体温37.5℃,脉搏98次/分,呼吸20次/分,血压120/70毫米汞柱。发育正常,营养中等,神清,呼吸平顺,体位自如。皮肤无黄疸,无皮疹或出血征,无蜘蛛痣。
Summary of patient history (hospital number 15960) male, 37 years old, mid-January 1976, persistent upper abdominal pain during travel, with nausea, anorexia, fatigue, no fever. Service “stomach Shuping” does not ease, sick after 5 days, solution of black loose stool, 1-2 times a day. 3 days before admission, suddenly nausea, vomiting dark red bloody stomach content of about 300 ml, February 4, 1976 to our hospital. Past “stomach” history. In the past 5 years there was a history of exposure to water and water, denying any schistosomiasis and no history of jaundice or hepatitis. Non-smoking alcohol hobby. No special family history. Admission examination, body temperature 37.5 ℃, pulse 98 beats / min, breathing 20 beats / min, blood pressure 120/70 mm Hg. Normal development, moderate nutrition, clear, breathe smoothly, position freely. No jaundice in skin, no rash or bleeding, no spider nevus.